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Robert J. Pizzutiello, MS, FACR, FAAPM, FACMP

Senior Vice President, Imaging Physics

President, Upstate Medical Physics –

A LANDAUER Medical Physics Partner

CT Protocol Review:Practical tips for the Imaging Physicist

• How to • Come up to speed on a wide range of

scanner types• Leverage your experience from one site to

others• Build relationships that encourages your

client to seek your input on protocols• Address protocol problems once you

find them, particularly if the site isn’twilling to pay for support

• Utilize AAPM support tools

Objectives

• What is a consultant?• Scope of the project• Benefits and Challenges for the

Consultant• Technical• Operational• Professional

• Recommendations (Advice)• AAPM WG CTNP and

TG 225 Practice Guidelines

Outline

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• 33 year old pregnant (18 weeks) female presents with severe headaches and labored breathing

• ER physician orders CT scans • Head • Chest (r/o PE)

• OB/GYN consult• Neurologist consult• Radiologist consult• Medical Physics consult

Who is a consultant?

• Main Entry: con·sul·tant • Pronunciation: \kən-ˈsəl-tənt\• Function: noun

• Date: 1697• 1 : one who consults another

2 : one who gives professional advice or services : expert

Who is a consultant?

http://www.merriam-webster.com/dictionary/consultant

• According to traditional medical use of the term, “consultant” is not the patient’s primary care provider but has expertise that contributes to patient care

• According to dictionary, we are all consultants• All medical physicists are “consultants”• Issues for FTE hospital staff medical physicists

may be somewhat different• FTE Staff Medical Physicists share much in

common with “consultants”

Who is a consultant?

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• Diversity of manufacturers and models• Use same process as when starting ACR CT support • Start with one or two sites and CT scanners• Allow extra time to refine the process

• Consider reduced or no-charge at first

• Choose receptive site (management, personnel, schedule)

• Form and lead the CT Protocol Review Committee• Build your own scanner-specific protocol table

• Use AAPM “CT Protocols” resources

• Pilot the project and identify success milestones

Technical Benefits, Challenges

• Obtain grassroots support – find an on-site Champion

• Present the case to decision makers• Lock down all protocols, subject to approval• Form “CT Protocol Review Committee”

• Radiologist, CT Technologist, Medical Physicist• Use AAPM TG 225 for support

• Start by reviewing this document with the leadership

Scope of Protocol Review project

• Start with highest dose impact/volume studies Perfusion and Pediatrics

• Review clinical considerations, dose, protocol details

• Minimize number of protocols• Educate members about patient dose vs. CTDI• Agree on CTDI ranges for key exams

• And what to do if they are exceeded• Generate recommendations (trial solutions)• Meet regularly and re-evaluate• Evaluate more protocols• Document process and results

Scope of Protocol Review project

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Sample Protocol Sheets

• Opportunity and challenge• Start with data from AAPM

• AAPM Summit Lectures• AAPM TG 225 report, in process • AAPM CT Protocols web site

• Use other web and Mfr resources• Start your own database – and grow it!

• “At another site with this scanner, we did…”

• Network with other medical physicists

Diversity of Manufacturers – Models

• kV• 120 kVp for average adults• 100 kVp for small adults • 80 – 100 kVp for peds• 140 kVp for very large adults

• Change kVp to maintain noise• If increase from 120 – 140 kVp, reduce mAs

by 40%• Reduces patient dose by about 20%• Increasing 120 – 140 kVp to reduce

streaking artifacts (shoulders and hips)

Create a list of “rules of thumb”

Adapted from Frank Ranallo, PhD

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• ImageThickness• Thinner slices produce better axial resolution

with less partial volume effect• Thinner slices require more mAs for equivalent

noise

• Image Recon Incrementation• For axial, slice incrementation = slice thickness• For helical, best z-axis resolution may be achieved

at recon interval = ½ thickness

Create a list of “rules of thumb”

Adapted from Frank Ranallo, PhD

• Pitch• Pitch <1 improves image quality, less helical artifact• Pitch >1 gives faster anatomical coverage (less

motion)• Motion is important for breath hold, peristalsis, etc.• On newer scanners in manual mode, consider

• lower pitch, • adjust rotation time needed for coverage/motion, • adjust mA for proper dose

• Automatic mode, adjust noise index (reference mAs)• Increase pitch to reduce scan time• Check maximum mA

Create a list of “rules of thumb”

Adapted from Frank Ranallo, PhD

• Study each manufacturer’s features,terms, quirks• We engaged an experienced CT physicist to consult

with us in January 2010 • You have the benefit of many recent AAPM activities

• Improve your understanding of clinical needs• We engaged an experienced CT radiologist to consult

with us in March 2010• Developed close relationships with CT focused

radiologists at two client sites• Review specific cases remotely, at their request

How do we prepare?

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http://www.pedrad.org/associations/5364/ig/index.cfm?page=614

http://spr.affiniscape.com/associations/5364/ig/index.cfm?page=368

Image Gently – mAs Reduction Factors for Peds

Abdomen Baseline:

kVp mA Time (sec) Pitch Abdomen Pitch Thorax

120 200 0.5 1 1

PA Thickness (cm)

ApproxAge

Abdomen Thorax

mAs Reduction Factor (RF)

Estimated mAs = BL x RF

mAs Reduction Factor (RF)

Estimated mAs = BL x RF

9 newborn 0.31 31 0.29 29

12 1 yr 0.36 36 0.34 34

14 5 yr 0.61 61 0.57 57

16 10 yr 0.71 71 0.63 63

19 15 yr 0.77 77 0.69 69

22 small adult 0.91 91 0.84 84

25 med adult 1.0 100 0.93 93

31 large adult 1.33 133 1.21 121

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Manufacturer’s web sites and other resources can be helpful

http://www.ctisus.com

• Daunting size of this project• Requires

• Significant institutional will• Significant resources • Significant cooperation

• Could potentially be largest patient benefit • From Image quality, Dose and ALARA perspectives

• Process/results useful for • Professional development• Marketing in a competitive environment

(sites and MP)

Operational Benefits, Challenges

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Do the math –How many protocols are there?

Hospital Small Med Large 16 16 64

– Head 16 16 18

– Ear 5 4 8

– Soft Tissue 1 4 8

– Spine 2 9 10

– Ortho (Extrem) 2 2 31

– CTA 3 11 15

– Cardiac 0 0 6

– Chest 7 17 12

– Abdomen 13 23 15

– Pelvis 2 2 6

Total 44 88 131

• “There is no $ in the (dept operating) budget”• “CT schedule is full all the time”• “We will irritate referring MD’s”• “No radiologist is willing to spend the time”• “All radiologists will never agree to

standardization”• “Technologists are too busy”• “All protocols are fine” (set by manufacturer)

• (Ignorance is bliss)

• “No regulatory requirement”

Obstacles

• Make a difference• Professional development

• Expand our technical and clinical understanding• ABR MOC

• Become “essential” and not easily replaced by others without this understanding

• Build relationships with RT’s and Radiologists• Increased visibility

• to staff, radiologists, management, administrators

• Create and refine a new MP service “product”

Benefits to the medical physicist

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Collaborating toBring a Unique Solution

• Time, travel (labor intensive project)• On-site monthly meetings• On-going project• Documentation of recommendations• Telephone calls as project progresses

• $ (hard to receive optimal comp)• Consider as a partial “loss leader”

• Professional growth• Future new service offering (growth)

• Do we have the staff?• Consider residents, physics assistants for

data collection (R&F, CR, etc.)• Use senior CT experienced physicists and

residents for this project

Costs to the medical physicist

• Need to sell the concept of CT protocol review –• Need an internal, powerful Champion

• Natural progression from ESE and ESER (R&F)• RSO or Supervising Radiologist (TJC) is responsible

for patient doses• State regulations may soon specify CT Dose Review • Medical physicist must commit to, and truly be

• Available for consultation• Knowledgeable (technically, clinically) or willing to learn• Willing to participate as a team member• Invest the ongoing effort to make this work• Step beyond the “testing” comfort zone and truly “consult”

• Recall experience with mammo technique charts

Building Relationships

• Patient Care (General)• Useful when answering questions

(specific patient)• “We have reviewed all of our protocols ….”

• ABR MOC• Risk Management• Communication with referring physicians

• Marketing: “We are doing this new project…”

• TJC Sentinel Alert

Motivations for Radiologist

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TJC Sentinel Alert

• 6. Radiologists should assure that the proper dosing (sic) protocol is in place for the patient being treated.

• 7. Institute a process for the review of all dosing (sic) protocols either annually or every two years to ensure that protocols adhere to the latest evidence.

“Right Dose”

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PQI:

Practice Quality

Improvement

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No one wants to be Front-Page Headlines

This image cannot currently be displayed.

• Build on past successes• ACR CT Accreditation (3 protocols, then 4)• Image Gently• ESE analysis• CR Exposure index (s-number, LgN, EI, etc.)

• Start with CT technologist and Radiologist• Remind others of Congressional hearings

• Statements from AAPM, ACR, etc.

• FDA position April 20, 2010

Building relationships

Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging

FDA is launching a collaborative Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, with

a focus on the types of imaging procedures that are associated with the highest radiation doses: CT, fluoroscopy,

and nuclear medicine.

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• …two principles of radiation protection: appropriate justification for ordering and performing each procedure, and careful optimization of the radiation dose used during each procedure.

• These types of imaging exams should be conducted only when medically justified.

• When such exams are conducted, patients should be exposed to an optimal radiation dose – no more or less than what is necessary to produce a high-quality image.

• In other words, each patient should get the right imaging exam, at the right time, with the right radiation dose.

• Why should facilities engage in protocol review• Quality Patient Care• Risk Management• Patients are asking “What is my dose from CT”

• Would be helpful to respond “We are engaged in an ongoing review process to assure ALARA?”

• Potentially emerging (or new interpretations of) regulations and accreditation requirements

• MP Consider “no charge” first client while you are learning

• Reference this success to other clients

Salesmanship 101

Collaborating toBring a Unique Solution

• Radiology Manager • RSO • Radiation Safety

Committee • Hospital

Administrators• Risk Management• Hospital Board of

Directors

Salesmanship 101 – Decision makers

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• Why should facilities engage in protocol review• Quality Patient Care• Risk Management• Patients are already asking

“What is the dose from CT”• Would be helpful to respond “We are engaged

in an ongoing review process to assure ALARA”

• Potentially emerging regulations, accreditation requirements or interpretations

Salesmanship 101 The Project

Addressing contributing factors to eliminate avoidable radiation dosing (sic)There are actions that organizations can take to eliminate avoidable radiation. First, staff should be aware of the contributing factors to, and activities that can help eliminate, avoidable radiation doses, which include: …….

• Knowledge regarding typical doses. • Clear protocols that identify the maximum dose for

each type of study. • Consulting with a qualified medical physicist when

designing or altering scan protocols. • Communication among clinicians, medical physicists,

technologists and staff.

Issue 47, August 24, 2011

6. Radiologists should assure that the proper dosing (sic) protocol is in place for the patient being treated.

7. Institute a process for the review of all dosing (sic) protocols either annually or every two years to ensure that protocols adhere to the latest evidence.

8. Investigate patterns outside the range of appropriate doses. Track radiation doses from exams repeated due to insufficient image quality or lack of availability of previous studies to identify the causes. Address and resolve these problems through education and other measures.

“Right Dose”

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Personnel to Support Project…

Time $$$ Staff MDs

CT RT (Spvsr)Radiology Mgr

Pt care, standardization+ operating budget

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RadiologistPt care, standardization,Referring MDs, legal

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RSC - RSO No incidents; compliance � � ����

AdminRisk Mgmt

Avoid incidents;Publicity; Legal

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Bd of Directors Publicity, personal legal risk ������������ �

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ConcernsAuthority

“What have you done to assure media incidents don’t happen here?”

Avoid incidents; compliance

Essential Personnel to Support

Project… Time $$$ Staff MDs

CT RT (Spvsr)

Radiology Mgr

Pt care, standardization

+ operating budget

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RadiologistPt care, standardization,

Referring MDs, legal�

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RSC - RSO � � ����

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Risk Mgmt

Avoid incidents;

Publicity; Legal

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ConcernsAuthority

A few

• Teaching technologists is win-win

– How their scanner works

– Meaning of CTDI and DLP displays

– Set trigger levels

• Carefully document process and recommendations

of advice…

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Teaching CT Technologists about Dose Info

Adapted from Doug Pfeiffer, MS

How to present/document recommendations

• Observation: The default __ protocol was initially set for __, for which (dose, image quality) may not be optimal. These have been discussed with the CT Protocol Review Committee

• Recommendation: Consider modifying the protocol ___ to improve (dose, image quality) as documented in Committee Minutes. Dr. Rogers to assess clinical acceptability. Notify Committee members if problems are reported.

• Caution: Changing default protocols without team consensus could compromise patient care (image quality and dose).

If facility isn’t willing to pay for more support…

• Added Caution: Changing default protocols without a medical physics consultation could compromise patient care.

• CTDI displays are not patient dose displays and can be complex to interpret. Without further medical physics consultation regarding changes, we are unable to assess the potential for patient injury due to excessive radiation exposure.

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If site is unwilling to start paying for support…

• Added Caution: This report of routine medical physics service is limited to evaluation of image quality and dose for specific protocols specified in the ACR CT accreditation program (routine head, abdomen and pediatric abdomen).

• We have not been engaged to participate in an overall review of facility protocols. Hence, we are unable to assess the potential for patient injury due to excessive radiation exposure from protocols we have not been retained to evaluate.

AAPM Resources

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Organization of Practice Guideline

• Introduction

• Definitions

• Staffing Qualifications and Responsibilities

– Protocol Review and Management Team

– CT radiologist, CTRT, In-house MP, Consulting MP

• Essential Elements of the Protocol Mgmt Process

• Recommended Elements of the Protocol Mgmt Process

• Conclusion

Coming soon!

AAPM CT Tools

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CT Scan Protocols

• Statement of Purpose

• Model & Equipment Performance Questions

– Contact info

• Role of QMP

• CT Dose Check Standard Guidelines

• Protocols

• Lexicon

– Translation of Terms for different manufacturers

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AAPM CT Lexicon ver 1.2 03/20/2012

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• Start with highest dose impact/volume studies Perfusion and Pediatrics

• Review clinical considerations, dose, protocol details

• Minimize number of protocols• Educate members about patient dose vs. CTDI• Agree on CTDI ranges for key exams

• And what to do if they are exceeded• Generate recommendations (trial solutions)• Meet regularly and re-evaluate• Evaluate more protocols• Document process and results

Scope of Protocol Review project

Summary

How to

Come up to speed on a wide range of scanner types

Leverage your experience from one site to others

Build relationships that encourages your client to seek your input on protocols

Address protocol problems once you find them, particularly if the site isn’t willing to pay for support

Utilize AAPM support tools

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Thank you!